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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> ! Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District.. <br /> Job AddressZaM/ Cityyeen4Lot Size PM - <br /> Owner's Nam r Address / /V. <br /> Phone <br /> � r <br /> Contract &Adtlress s� License N032 <br /> TYPE OF WELL/PUMP: �Phon C <br /> ,p15— <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ' <br /> C DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r <br /> ❑ Industrial ❑ Open Bottom G Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing � Specifications <br /> Irrigation f"1 Public 1-1Otherf-1 Delta Depth of Grout Seal <br /> I i Type of Grout <br /> —..Approx. Depth f I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H,P. State Work Done_ <br /> Well Destruction E] Well Diameter Sealing Materia! {top 50') <br /> Depth Filler Material 18elow 50'1 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is �} <br /> 4 ' <br /> Installation will serve: Residence Commercial_ Other available within 200 feet.) <br /> Number of living units:_ Numb*iLbjeoml Character of soil to a depth of.3 feet:SEPTIC TANK Waier table depth <br /> Type%Mfg Capacity s�S+ fJo. CompartmentsPKC:=TREATMENT PLT. ❑ � . ; 4 <br /> f` r ,_« Method of.Disposal I <br /> t Distance to-nearest: Well '' I <br /> Foundation ��__ Property.Line <br /> LEACHING LINE No. & Length of lines Q , <br /> ° Total length/size d X <br /> 'FFLTER BED ❑ Distance to nearest: ,.V1lel! �' <br /> Foundion <br /> � Fti Property Line <br /> SEEPAGE PITS f I Depth Size: <br /> x.l�'-•_. �. umber <br /> SUMPS Distance to nearest: ~Welles <br /> X - Foundation!- /� Property Line <br /> DISR45AL PONDS <br /> I hereby certify that I have prepared this application and that the work-will-be done in-accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of tti'e San Jriaquin Local Health District. �. <br /> Home owner or licensed agent's signature certifies the followin <br /> employ an g:='I ceitify,that.in.the performance of the work for which this permit is issued, I shall not <br /> p y y person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work-foe whicfr this <br /> tion laws of California." permit is issued, I shall employ personsisdNjEct to workman's compensa- <br /> - <br /> The applicant st call fo Ile wired inspections.,Complete drawing on-reverse's <br /> Signed X Title: t - 1 , <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by�1 <br /> t Date r Area <br /> -�Crfd s ec iaby Date '- Final Inspection by <br /> Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> _- INFO CK RECEIVED BY <br /> •-- - CASH PATE PERMI7'NO. <br /> +.EH 13-24(REV.v n 91 `,f <br /> EH 14-26 � �- <br />